Post on 18-Jul-2016
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Focus on Disorders of the Aorta 4/7/2014
(Relates to Chapter 38, “Nursing Management: Vascular Disorders,” in the textbook)
Learning Outcomes
Safe and Effective Care Environment
Collaborate with interdisciplinary healthcare team members when providing care for patients with vascular problems
Health Promotion and Maintenance
Identify risk factors for vascular problems
Teach patients about lifestyle modifications to prevent vascular problems
Learning Outcomes
Physiologic Integrity
Monitor for complications of vascular surgery
Perform a focused vascular assessment
Disorders of the Aorta
Most common vascular problems of aorta
Aneurysms
Aortoiliac occlusive disease (like PAD)
Aortic dissection
Aorta
Largest artery
Responsible for supplying oxygenated blood to essentially all vital organs
Aortic Aneurysms Definition: something happens to the arterial wall
Outpunching’s or dilations of the arterial wall
Common problems involving aorta
Occur in men more often than in women
Incidence ↑ with age
See gender Differences, p. 867
Abdominal aortic aneurysms (AAA) (you can have multiple aneurysms!)
Occur in 4.1% to 14.2% of men
0.35% to 6.2% of women over 60 years of age
Cause of 16,000 deaths per year
In Canada, account for 0.7% of all mortalities
Aortic Aneurysms Etiology and Pathophysiology
May involve the aortic arch, thoracic aorta, and/or abdominal aorta
Most are found in abdominal aorta below renal arteries
¾ of true aortic aneurysms occur in abdominal aorta
¼ found in thoracic
May have aneurysm in more than one location
Growth rate unpredictable
Larger the aneurysm greater risk of rupture
The bigger it gets is more likely it is to POP (like a balloon) ***
Dilated aortic wall becomes lined with thrombi that can embolize
Leads to acute ischemic symptoms in distal branches
Can cause changes in all extremities*
Causes:
Degenerative: most common**( atherosclerosis)
Congenital:
Familial tendency related to abnormalities*(don’t know why)
Ehlers-Danlos syndrome and Marfan syndrome
Mechanical:
Penetrating or blunt trauma**
Atherosclerotic plaques deposit beneath the intima: DISEASE CAN HAPPEN ANYWHERE**
Plaque formation is thought to cause degenerative changes in the media***
Leading to loss of elasticity, weakening, and aortic dilation
Male gender and smoking stronger risk factors than hypertension and diabetes*****
Inflammatory
Takayasu’s or giant cell arthritis
Infectious
Syphilis, Salmonella, HIV
Most common cause is atherosclerosis ****
Studies suggest strong genetic predisposition
Aortic Aneurysms Classification:
2 Basic classifications
True
False (pseudo aneurysm)
True aneurysm:**
Wall of artery forms the aneurysm
At least one vessel layer still intact (outermost layer)**
Further subdivided:
Fusiform (both sides of artery)
Circumferential, relatively uniform in shape
Saccular
Pouch like with narrow neck connecting bulge to one side of arterial wall
False aneurysm:
Also called pseudo aneurysm
Not an aneurysm***
Disruption of all layers of arterial wall****
Results in bleeding contained by surrounding structures
May result from
Trauma
Infection
After peripheral artery bypass graft surgery at site of anastomosis (NOT SUTURED CORRECTLY)
Arterial leakage after cannula removal
Thoracic aorta aneurysms: (VERY BAD)***
Often asymptomatic*
Most common manifestation (as aneurysm gets bigger symptoms progress)**
Deep, diffuse chest pain (can mimic angina pain) (1ST sign)
Pain may extend to the interscapular area
Ascending aorta/aortic arch
Produce angina
Hoarseness
If presses on superior vena cava:**
Decreased venous return can cause:
Distended neck veins
Edema of head and arms
SUPERIOR VENA CAVA SYNDROME**
Abdominal aortic aneurysms (AAA) (PATIENT FEELS FINE) **
Often asymptomatic
Frequently detected:
On physical exam:
Pulsatile mass in per umbilical area
Bruit may be auscultated
When patient examined for unrelated problem (i.e., CT scan, abdominal x-ray)
NORMAL FINDING: PULSATING AROUND THE AORTIC REGION ON 86 YEAR OLD MAN VERY THIN**
YOU WILL FEEL A MASS INSTEAD OF A PULSATION**
YOU WILL ALSO HEAR BRUIT THROUGH STETHOSCOPE* (TURBULANCE OF BLOOD GOING THROUGH DILATED AREA)
KNOW DEEP PALPATION OR IT CAN CAUSE THE ANEURYSM TO RUPTURE** DO NOT KILL YOUR PT
May mimic pain associated with abdominal or back disorders***
If aneurysm is posterior (pain in back)
If aneurysm is anterior (abdominal pain)
May spontaneously embolize plaque
Causing “blue toe syndrome”**
Patchy mottling of feet/toes with presence of palpable pedal pulses**** toes look cyanotic **
Aortic Aneurysm Complications:***
Rupture—serious complication related to untreated aneurysm
Posterior rupture: ( YOU WANT THIS ONE)** a lot of stuff that could by you more time to get fixed**
Bleeding may be tamponaded by surrounding structures, thus preventing exsanguination and death***
Severe pain (agonizing back pain)**
May/may not have back/flank ecchymosis **
You will see signs of bleeding**
Anterior rupture: NOT GOOD-MEDICAL-SURGICAL EMERGENCY!!!!****
Massive hemorrhage
Most do not survive long enough to get to the hospital***
Aortic Aneurysm Diagnostic Studies ****
X-rays (can show widening of the aorta) (something wrong)**
Chest—Demonstrate mediastinal silhouette and any abnormal widening of thoracic aorta
Abdomen—May show calcification within wall of AAA
ECG to rule out MI (make sure it is not cardiac)**
Echocardiography**
Assists in diagnosis of aortic valve insufficiency
Related to ascending aortic dilation
Closer to aortic route (prone to aneurysms)**
Ultrasonography (once an aneurysm is diagnosed)**
Useful in screening for aneurysms
Monitor aneurysm size (they keep an eye on it to see if it is growing)**
Pt will come in every 6 months for further evaluation and growth**
CT scan (most accurate)*****
Most accurate test to determine
Anterior to posterior length
Cross-sectional diameter
Presence of thrombus in aneurysm
MRI
Diagnose and assess the location and severity
Angiography (is not routinely done to dx)**
Anatomic mapping of aortic system using contrast
Not reliable method of determining diameter or length
Can provide accurate info about involvement of intestinal, renal, or distal vessels****
Aortic Aneurysm Collaborative Care: Table 38-1***
Goal—to prevent aneurysm from rupturing
Early detection/treatment imperative
Once detected: (must go for further f/u)** *(they need to do what they’re supposed to do or else DEATH)**
Studies done to determine size and location
If carotid and/or coronary artery obstructions present
May need to be corrected before repair*
THEY WONT SURVIVE SURGERY IF THEY HAVE CAD****
Small aneurysm (<4 cm) (YOU WILL WATCH IT) (PT WILL GO FOR REGULAR FOLLOW UPS TO SEE IF IT IS GETTING BIGGER)***
Conservative therapy used: (LIFE STYLE MODIFICATIONS)**
Risk factor modification
↓ Blood pressure****
Ultrasound, MRI, CT scan monitoring q 6 months
YOU MUST GO FOR F/U******
5.5 cm is threshold for repair (men)** ****
Intervention at <5.5 cm in women with AAA
they only perform surgery if it is needed**
No strict criteria (depending on woman)
Surgical intervention may occur earlier in
Younger, low-risk patients (trauma)
Will consider surgery
Rapidly expanding aneurysm
Symptomatic patient* (back pain, abdominal pain)
High rupture risk (if aneurysm is growing fast they will take the pt to OR before it ruptures)***
Older, high-risk patients: (with co-morbidities)
Endovascular repair may be treatment of choice****
No OR. PT WILL NOT SURVIVE**
Surgical Therapy ****
If ruptured, emergent surgical intervention required
33%-94% mortality with ruptured AAAs*** (BAD)
Preop: ** (routine pre-op care)**
IV FLUIDS, NPO, BOWEL PREP, SPINTING, COUGHING AND DEEP BREATHING, INSENSTIVE SPIROMETY, AMBULATION
Hydration
Lab work (make sure pt is not bleeding)** (H&H)
HEMOGLOBIN: 12-15%
HEMATOCRIT: 35-47%
Electrolyte, coagulation, hematocrit stabilized
Make sure you have blood on hand**
Surgical Technique: (38-4) *** (SLICE INTO IT, OPEN UP AND TAKE OUT PLAQUE, THAN PUT A GRAFT IN)
Incising diseased segment of aorta
Removing intraluminal thrombus or plaque
Inserting synthetic graft
Dacron or polytetrafluoroethylene (PTFE)
Suturing the native aortic wall around graft
Acts as protective cover
Aortic Aneurysm Collaborative Care: ****
Auto transfusion reduces need for blood transfusion during surgery**
DON’T HAVE TO WORRY ABOUT TRANSFUSION REACTION**
THE BLOOD THAT IS COMING OUT OF PT WILL GO RIGHT BACK IN***
AAA resections**
Require cross-clamping of aorta proximal and distal to aneurysm
Can be completed in 30-45 minutes
Clamps are removed and blood flow to lower extremities restored**
If extends above renal arteries or if cross clamp must be applied above renal arteries
Adequate renal perfusion after clamp removal should be ascertained before closure of incision
Risk of postop renal complications ↑ significantly when repair is above renal arteries*** (KEEP A GOOD WATCH ON PT KIDNEY STATUS)**
Post op Complications: Aortic Aneurysm **
WILL BE IN ICU** Asses VS/ circulation q15 minutes**, than hourly once they hit parameters provider wants, Pulses are starting to diminish call provider***, make sure those pulses are clearly marked** check in the same spot**, change in color of extremities, if pt is experiencing pain other than incisional pain, make sure you measure abdominal circumferences, watch URINE OUTPUT** (HOURLY)**
Endovascular graft procedure:****
Alternative to conventional surgical repair****
Involves placement of suture less aortic graft into abdominal aorta inside aneurysm
Done through femoral artery cut down
Graft:
Constructed from Dacron cylinder
Surface supported with rings of flexible wire
Delivered through sheath to predetermined point
Deployed against vessel wall by balloon inflation
Anchored to vessel by series of small hooks
Blood flows through graft, preventing expansion of aneurysm
Aneurysm wall will begin to shrink over time (shrivels up from lack of blood)**
Must meet strict eligibility criteria to be candidate
Benefits:***
↓ anesthesia and operative time
Smaller operative blood loss
↓ morbidity and mortality
More rapid resumption of physical activity
Shortened hospital stay
Quicker recovery
Higher patient satisfaction
Reduction in overall costs
Potential complications: (BAD THINGS CAN STILL HAPPEN)**
Aneurysm growth
Aneurysm rupture
Per graft leaks***
Aortic dissection****
Bleeding (BLOOD PRESSURE MUST BE KEPT IN ACCEPTABLE PARAMETERS)**
Graft dislocation and embolization
Graft thrombosis
Incisional site hematoma
Site infection
Most common complication is per graft leak**
Seeping of blood from new endograft into old aneurysm site
Graft dysfunction may require traditional surgical repair**
With endovascular repair
Higher reintervention rate
Need for long-term follow up*** (MIGHT NEED TO HAVE MORE THAN ONE)
Long-term complications not known**
New approach is percutaneous femoral access***
Advantages:
Shorter operative time
Shorter anesthesia time
Reduction in use of general anesthesia
Reduced groin complications within first 6 months
Thoracic Aneurism Collaborative Care : ***
Repair tailored to each patient
Ascending aorta repair requires cardiopulmonary bypass
Partial bypass used for descending thoracic aorta
Care similar to other thoracic surgeries
Review pp. 571-574**
Acute Intervention:
Expectations after surgery: TELL PT WHAT IS GOING TO HAPPEN WHEN THEY WAKE UP, THEY WILL PROBABLY BE INTUBATED**
Recovery room, tubes, drains, Foleys
ICU
Complications: CALL RAPID RESPONSE!!!**** (if pt is hemorrhaging)***
Assess vital signs more frequently and report changes to HCP**
Hemorrhage**** (look at chest tube drainage!)*****
800ml, low bp, high pulse
Ischemic colitis
Cerebral/spinal cord ischemia
Respiratory distress
Dysrhythmias (almost all of them)*
POST OP INTERVENTIONS**
Maintain graft patency*
Normal blood pressure (prescribed parameters for B/P) (your job to get them)
CVP or PA pressure monitoring**
Urinary output monitoring (Foley input and output)
Avoid severe hypertension:
Drug therapy may be indicated
Multiple IV drugs (IV HYPOTENSIVES MUST BE TITRATED) **
Nursing Management Assessment:**
Thorough history and physical exam (Head to toe)*
Watch for signs of cardiac, pulmonary, cerebral, lower extremity vascular problems***
Establish baseline data to compare postoperatively
Note quality and character of peripheral pulses and neurologic status:
Mark/document pedal pulse sites and any skin lesions on lower extremities before surgery *** VERY IMPORTANT***
Monitor for indications of rupture***
Diaphoresis
Pallor
Weakness
Tachycardia
Hypotension
Abdominal, back, groin, or per umbilical pain (LISTEN TO YOUR PT)**
Changes in level of consciousness***
Pulsating abdominal mass
Nursing Management Planning:
Overall goals include:
Normal tissue perfusion
Intact motor and sensory function
No complications related to surgical repair
Nursing Management Nursing Implementation:
Health Promotion
Alert for opportunities to teach health promotion to patients and their families
Teach patients with HTN the importance of taking prescribed drugs
Encourage patient to reduce cardiovascular risk factors
EVEN IF THEY FEEL FINE WATCH CLIENT FAT INTAKE
STOP SMOKING!!**** (ESPECIALLY MEN)**
These measures help ensure graft patency after surgery
Acute Intervention: (Pt has an aneurysm and needs surgery)***
Patient/family teaching
Providing support for patient/family (pt is very anxious)
Careful assessment of all body systems
Pre-op teaching**
Brief explanation of disease process
Planned surgical procedure
Pre-op routines*
Bowel prep (severe abdominal pain notify PCP)
NPO (NG TUBE) (POST OP)**
Shower
Postop **
ICU monitoring
Arterial line (CAN GIVE MEDS THROUGH)**
Central venous pressure (CVP) or pulmonary artery (PA) catheter
Mechanical ventilation (WILL BE ON MACHINE)**
Urinary catheter (INPUT AND OUTPUT EVERYHOUR)*
Nasogastric tube (A FEW DAYS UNTIL BOWEL SOUNDS RETURN) (PASSING GAS)*** THAN NG tube can come out
ECG
Pulse oximetry
Pain medication (PCA PUMP)
Cardiovascular status:
Continuous ECG monitoring (assess for dysrhythmias)
Electrolyte monitoring (LIGHTS AND 02)**
Arterial blood gas monitoring (ARTERIAL LINE)
Oxygen administration (ENDOTRACHEAL TUBE, and then mask, than nasal cannula)
Antidysrhythmic/pain medications
Infection: (PREVENTON)**
Antibiotic administration (PROPHLAXIS)
Assessment of body temperature***
Monitoring of WBC (IV fluids and then advanced fluids)
YOU WILL EXPECT A SLIGHT INCREASE AFTER SURGERY**
Adequate nutrition (IV fluids and then advanced fluids once NG tube comes out** )
Observe surgical incision for signs of infection**
Gastrointestinal status
Nasogastric tube
Abdominal assessment
Passing of flatus is key sign of returning bowel function
Watch for manifestations of bowel ischemia
4-5 days no passing of gas theirs a problem***
Peripheral perfusion status:
Extremity assessment
Temperature, color, capillary refill time, sensation and movement of extremities
Neurologic status:
Level of consciousness (very important call RAPID RESPONSE)****
Pupil size and response to light
Facial symmetry
Speech (CRANIAL NERVES)* (OCCUMOTER NERVE)*
Ability to move upper extremities
Quality of hand grasps
Pulse assessment:
Mark pulse locations with felt-tipped pen***
Renal perfusion status:
Urinary output
Strict input and output
Every drop must be accounted for**
Fluid intake
Daily weight (watch out for kidneys)**
CVP/PA pressure (fluid retention)**
Blood urea nitrogen/creatinine
Aortic Aneurism: To Review:***
Nursing Implications:
Assess VS/circulation q 15 min, then hourly
Report signs of graft occlusion/rupture (immediately)
Changes in pulses (2+) and now can’t find pulse
Cool/cold extremities below graft (color)
White or blue extremities/flank
Severe pain ***
Abdominal distention (pay attention, especially if abdomen increased in size) **
Decreased urine output **
Thoracic Aneurism: To Review***
Assess VS at least q hour
Assess for significant increase in drainage from chest tubes
Get someone right away**
Assess for sensation and motion in extremities***
Ambulatory and Home Care:
Encourage patient to express concerns
Patient instructed to gradually increase activities (they need too)
No heavy lifting (watch for restrictions)**
Don’t pick up grand kid
Stool Softeners (NO STRAINING)**
Educate on signs and symptoms of complications (very important) *
Infection (SPIKE IN TEMP, PRODUCTIVE COUGH)
Neurovascular changes (FEEL GOING NUMB)***
Nursing Management Evaluation:
Expected Outcomes:
Patent arterial graft with adequate distal perfusion
Adequate urine output (KIDNEYS ARE HAPPY THEY MAKE PLENTY OF URINE)
Normal body temperature
No signs of infection
Aortic Dissection (Part 2)**
Often misnamed “dissecting aneurysm” (more like a hematoma)**
Not a type of aneurysm****
Occurs most commonly in thoracic aorta
Result of a tear in the intimal lining of arterial wall
Blood flows into crack and creates a false lumen*
Affects men more often than women
Occurs most frequently between fourth and seventh decades of life
Acute and life threatening **
Mortality rate 90% if not surgically treated*****
Aortic Dissection Etiology and Pathophysiology
Tear in intimal lining allows blood to “track” between intima and media (collects in the middle)**
Creates a false lumen of blood flow
As heart contracts, each systolic pulsation ↑ pressure on damaged area
Further ↑ dissection
May occlude major branches of aorta:
Cutting off blood supply to brain, abdominal organs, kidneys, spinal cord, and extremities*** (depending on the location) (going into the false lumen instead of the organs, where it is supposed to go)**
Cause is uncertain
Many attribute to destruction of medial layer elastic fibers
Most people with dissection are older with chronic hypertension
Persons with Marfan syndrome ↑ incidence
Blunt trauma can precipitate
Aortic Dissection Clinical Manifestations:
Depend on location of intimal tear and extent of dissection
Where and how large the tear is***
Pain characterized as: (sudden onset)***
Sudden, severe pain in anterior part of chest or intrascapular pain radiating down spine to abdomen or legs
FEELS LIKE SOMETHING TORE INTO HIS CHEST*
Described as tearing or ripping
May mimic that of MI (DO NOT GIVE HEPARIN)***
As dissection progresses, pain may be above and below diaphragm
Cardiovascular, neurologic, and respiratory signs may be present
If aortic arch involved (loss of circulation)**
Neurologic deficiencies may be present
Aortic Dissection Complications :
Cardiac tamponade:***
Severe, life-threatening complication***
Occurs when blood escapes from dissection into pericardial sac
Cardiac output takes a nose dive**
Clinical manifestations include: (cardiogenic shock)**
Hypotension (very severe) (70/60) (heart is not moving)
Narrowed pulse pressure
Distended neck veins (JVD) (clear lung sounds)
Muffled heart sounds
VERY FAR AWAY (BLOOD ALL AROUND THE HEART)**
Tachycardia (affects the SA node)
Than bradycardia**
Dyspnea
Fatigue
Pulsus paradoxus*****
TAKE BLOOD PRESSURE TWICE* ASK PT TO BREATHE IN THE B/P WILL DROP**
Aorta may rupture:
Results in exsanguination and death***
Hemorrhage may occur in mediastinal, pleural, or abdominal cavities
Occlusion of arterial supply to vital organs (AORTA CAN NOT CONTAIN IT ANYMORE SO IT POPS)**
Aortic Dissection Diagnostic Studies:
Health history and physical exam
ECG (RULE OUT MI)** (WILL BE NORMAL)
CXR (WIDENING OF THORACIC AORTA)
CT scan/MRI (DEFINITIVE DIAGNOSIS)** ***
Trans-esophageal echocardiogram (if pt makes it that far it is useful)**
Left ventricular hypertrophy from systemic hypertension
Chest x-ray
May show widening of mediastinal silhouette and left pleural effusion
Trans esophageal echocardiogram
Identify dissections closest to aortic root
MRI or multi-detector row CT scan *** (gives good visual visualization)
Emergency diagnostic procedures of choice
Provide information on presence and severity of dissection
Angiography
Assess extent of dissection
Aortic Dissection Collaborative Care: Table 38-1
Initial goal (what do you want to do?)
↓ BP and myocardial contractility to diminish pulsatile forces within aorta**
Beta blockers (negative inotropes) (they decrease contractibility)**
Drug therapy:
IV β-adrenergic blocker****
Esmolol (Brevibloc) ** (drug of choice)****
Other hypertensive agents:
Calcium channel blockers
Sodium nitroprusside (only if b/p is extremely high and very powerful)
Angiotensin-converting enzyme inhibitors
Fenoldopam (Corlopam) IV
Conservative therapy
If no symptoms
Can be treated conservatively for a period of time
Success of the treatment judged by relief of pain
Emergency surgery is needed if involves ascending aorta*****(brain or heart)
Surgical therapy**
When drug therapy is ineffective or when complications of aortic dissection are present
Heart failure, leaking dissection, occlusion of an artery
Surgery is delayed to allow edema to decrease and permit clotting of blood
Involves resection of aortic segment and replacement with synthetic graft material
Take out diseased area and graph it into place
Extent of replacement depends on extent of dissection
Even with prompt surgical intervention:
30-day mortality rate of acute aortic dissections remains high (10%-28%)
Aortic Dissection: Nursing Management
Pre-op
Semi-Fowler’s position** (low puts pressure on aorta)
Maintaining a quiet environment (try to keep noise down and lights low)*
Decrease stimuli***
Anxiety and pain management:
Opioids and tranquilizers as ordered (raises B/P)
GIVE ANIXETY MEDS**
Continuous IV administration of antihypertensive agents
Continuous ECG and intra-arterial pressure monitoring
Observation of changes in quality of peripheral pulses
Frequent vital signs (depending on pt)**
Postop
See aneurysm postop care (discussed earlier)
SAFETY****
Discharge teaching***
Therapeutic regimen
Antihypertensive drugs and side effects
If pain returns or symptoms progress, instruct patient to seek immediate help!!
EVEN IF YOU FEEL FINE YOU MUST CONTINUE MEDS !!!
ANY CHANGES MUST GO TO HOSPITAL!!*****
Questions:
1. (32:55) Your pt had abdominal aortic surgery repair yesterday urine output is 25ml/hr. and BUN is 68. What is the priority intervention? Normal: BUN: 8-25mg/dl
a. Assess Vital signs (ALWAYS GET VITAL SIGNS BEFORE YOU CALL PROVIDER)** b. Increase the IV Fluid ratec. Continue to assessd. Call the surgeon immediately